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ICD-10 is the 10th revision of the International Classification of Diseases (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. [1]
In particular the paper medical record standard 'AS 2828' created by Standards Australia focuses on a few key areas that are critical to maintaining a legible paper medical record. [7] The following criteria should be used as a guideline when creating a medical record specific to the aid of providing clear documentation for diagnostic coding.
List of medical abbreviations: Overview; List of medical abbreviations: Latin abbreviations; List of abbreviations for medical organisations and personnel; List of abbreviations used in medical prescriptions; List of optometric abbreviations
The ICD-10 Clinical Modification (ICD-10-CM) is a set of diagnosis codes used in the United States of America. [1] It was developed by a component of the U.S. Department of Health and Human services, [ 2 ] as an adaption of the ICD-10 with authorization from the World Health Organization .
ICD-10-CA is a clinical modification of ICD-10 developed by the Canadian Institute for Health Information for morbidity classification in Canada. ICD-10-CA applies beyond acute hospital care, and includes conditions and situations that are not diseases but represent risk factors to health, such as occupational and environmental factors ...
Abbreviation Meaning Δ: diagnosis; change: ΔΔ: differential diagnosis (the list of possible diagnoses, and the effort to narrow that list) +ve: positive (as in the result of a test) # fracture: #NOF: fracture to the neck of the femur ℞ (R with crossed tail) prescription: Ψ: psychiatry, psychosis: Σ: sigmoidoscopy: x/12: x number of ...
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The ICD-10 Procedure Coding System (ICD-10-PCS) is a US system of medical classification used for procedural coding.The Centers for Medicare and Medicaid Services, the agency responsible for maintaining the inpatient procedure code set in the U.S., contracted with 3M Health Information Systems in 1995 to design and then develop a procedure classification system to replace Volume 3 of ICD-9-CM.